Tuesday, 5 August 2014

Solving Ebola

The press have been discussing the current outbreak of Ebola in West Africa. They stress that it is an awful way to die, that there is no cure, and that health workers are dying despite apparently taking all necessary precautions. More learned writers have been explaining that Ebola is quite hard to catch unless you come into direct contact with contaminated bodily fluids, and that simple precautions should be enough to contain it. Yet other commentators are pointing out that the death rate is very low compared to other well known diseases, and that we need to keep the threat in perspective. So, we have an intelligence test item to solve.

The World Health Organization, in partnership with the Ministries of Health in Guinea, Sierra Leone, Liberia, and Nigeria announced a cumulative total of 1440 suspect and confirmed cases of Ebola virus disease (EVD) and 826 deaths, as of July 30, 2014. Of the 1440 clinical cases, 953 cases have been laboratory confirmed for Ebola virus infection. Previous outbreaks have been more often in the Congo, Gabon and Uganda.

Infectious disease dynamics can be modelled, and controlling this outbreak should be pretty easy, at least from a conceptual point of view. This disease is a short-incubation period (about three weeks), relatively low transmissibility, high lethality infection. Whereas a sneeze can transmit pathogens with great efficiency, hence the easy airborne spread of influenza, avoiding fluids is easier. Soap, water, disinfectants, protective clothing for nurses, body bags for victims, quick burial in chlorine covered graves or better still cremation, quarantine for all contacts, and the same procedures for those quarantined victims if they die: all of these should be sufficient. In terms of disease control it should be noted that men who have recovered from the disease can still transmit the virus through their semen for up to 7 weeks after recovery from illness. Severely ill patients require intensive supportive care. Patients are frequently dehydrated and require oral rehydration with solutions containing electrolytes or intravenous fluids. No specific treatment is available. New drug therapies are being evaluated. Barrier nursing is required to protect health staff, but the standards of protection required are very high, and hard to observe when health workers are subject to high ambient temperatures. If treatment is really unlikely to help victims, then in a big outbreak it might best to avoid attempts at close contact nursing, and rely on quarantine and subsequent disinfection as the best way to save more lives. Perhaps hydration packs distributed to homes under quarantine would be best, but that is for public health specialists to judge.

Why isn’t all this happening? Many of the locals either do not understand the transmission method (from forest animals like bats), or chose to disbelieve it, and are not changing their behaviours regarding funereal procedures, which involve bathing and kissing the corpse, all of which are part of altruistic respect for the dead person. The locals are also prey to false correlation: they see people who are mildly ill going into hospital, and then taken out dead soon afterward by space-suited Western health workers. In terms of Kahneman’s Type 1 fast and sloppy thinking, this is understandable. Ebola hospitals are dangerous places. Westerners in space suits are unusual and disturbing, and in fact even the notion of a hospital may be the wrong strategy in these outbreaks. However, if a populace suspect that health workers spraying disinfectant may be malevolently spreading bottled Ebola, then there is a massive health education challenge to be faced.

Western doctors very much want to help, but getting to the outbreak locations they quickly find that local facilities are inadequate, that barrier nursing is very difficult to achieve to a high standard and, although this is less often conceded, that nursing might be of little real help. However, early treatment improves outcomes, and about 40%  are pulling through at the moment.  Hence the wish to provide treatment, and some groups like Medecins sans Frontieres have not lost doctors to Ebola. Wanting to help others is humanity at its best. These missionary doctors write heart-wrenching diaries about families being wiped out, and about their lack of resources, about the stigma with which the afflicted are treated and about their guilt at seeing ill patients dying without comforters next to them. They don’t publically question why the countries in which they operate are in such a mess. The conventional answer is that they are poor and wracked by conflict.

Guinea, Sierra Leone, Liberia, and Nigeria, the countries in the front line of this particular outbreak, share West African environments. Sierra Leone and Liberia have a particular history, in that they were formed and settled to take repatriated American slaves. From some points of view, they should be models of governance. That has not been the case. If all these countries had been governed well even remote country hospitals would have had basic resources, and there would have been widespread knowledge of basic hygiene and disease control. Quarantine would have been explained, established and monitored.

Can we deduce anything from the failure to deal with the epidemic? The governments of these countries may have regarded their poorer citizens as being of little interest to them, living as they do in poverty in remote villages near tropical forests. Government officials tend to be snooty, and African governments have often disregarded the needs of their citizens. They say that they have given plenty of public health warnings, but the disease keeps spreading. Disasters test the morality of the organising structure, and those structures have often been found wanting.

Could it be that these countries simply don’t understand the threat and don’t understand how to deal with it, or that they don’t do so in sufficient numbers to provide an effective response?

Little is known with certainty about intelligence levels in these countries. Those governments do not measure cognitive ability, nor do they participate in the PISA and other international scholastic studies. If one gathers together various published papers on intelligence test results, then the IQ figures for the Congo are in the 64 to 73 range; for Guinea 70; for Ghana 60-80; for Nigeria 64-70; and Sierra Leone 64. Some of the samples are of reasonable size, one and a half thousand, so it is not all a patchwork of tiny studies, though there is plenty of room for improvement. The figures are so low by Western standards that they are hard to believe, but when educational elites in South Africa are tested they are often in the IQ 100 range, consistent with being the top 2% of a population which has an actual mean of IQ 70.

Botswana is an exceptional African country in many ways, has put a lot of money into education, and has participated in Trends in International Mathematics and Science 2011, and Progress in International Reading Literacy Study 2o11. Botswana is a test case, an exemplar of the current achievement of an African country which takes education seriously. If you look at their scholastic achievement and compare it with the achievements of countries with well established IQ measures, then Botswana comes out at an estimated IQ of 70. Sub-Sarahan African intelligence test results have been much debated by intelligence researchers, and the estimates range from about IQ 70 from Richard Lynn to IQ 80 from Jelte Wicherts. The key argument is about the representativeness of samples. The tests seem to be OK, much to popular surprise. Humans in all continents appear to solve basic problems in the same way. Africans have the same cognitive operating system as other continental groups. There are power differences, but not operating system incompatibilities.

Are the behaviours of the average citizens in these countries consistent with these estimates? Western critics of international intelligence testing regard these estimates with considerable scepticism, particularly considering that IQ 70 is seen as too low to lead an independent life and earn a living in Western economies. However, that is the way the results come out, and the match with achievements is reasonably close, certainly when scholastic achievements are measured. Although all countries have the equivalent of witchdoctors, in the West these are usually a homeopathic side-line and less dominant in public health, but in African countries they still sway many people on important health matters. Seen from afar, the response to Ebola has not been intelligent. Equally, the response to HIV has often been weak and contradictory.

Finally, should we be less alarmed about Ebola, and be more scared of measles, malaria and car accidents? Those who would ask us to bear in mind these comparative statistics misunderstand human nature. New threats demand great fear, which is the prudent reaction till the true nature of the predator is known. We humans are also concerned about how we die. Bleeding to death from a galloping haemorrhagic fever is far more scary than our favoured exit, to breathe our last as peacefully as possible, expiring gently, entirely unblemished, while lying in clean sheets in our own house with our loving family in attendance. Furthermore, as even the dullest actuary must know, the statistics on Ebola are comforting only at the moment. If this outbreak continues to be mismanaged, the numbers could look very different in a few year’s time. Then we would have to say that we had failed a simple test in public health.

Hope not.

1 comment:

  1. A "cognitive operating system" is an interesting way to put it. I imagine all people as having a common behavioral and cogitive "template" presumably because of our common origin pre-out-of-Africa. A common template but with differences that can be described as "statistical."

    I would imagine domestic dogs could be described the same way. As having a common cognitive/behavioral template but with statistical differences in degree of expression.